1. Pelvic Trauma

2. Lecture Outline ƒAssociated injuries ƒResuscitation ƒClassification ƒExample radiographs

3. Pelvic Trauma General Considerations ƒPelvis : ? The most important (or perhaps most favorite) area of the body (since it houses the sexual organs) ƒPelvic injuries often represent multi- system injuries ƒDefinitive management may require a subspecialist orthopedic surgeon

4. Pelvic Fractures Epidemiology ƒOverall mortality 6 to 19 % ƒIf hypotensive, mortality 40 to 50 % ƒ60 % due to motor vehicle crashes (MVC's) –Third most common cause of death from MVC's ƒ30 % due to falls ƒ10 % due to direct crush of pelvis ƒ65 % of deaths due to hemorrhage

5. Immediate Sequelae of Pelvic Trauma ƒMassive hemorrhage ƒBony disruption of pelvis ƒVascular interruption (major and minor) ƒUrologic injury ƒBowel and vaginal tears or perforations ƒNeurologic injury

6. Massive Hemorrhage from Pelvic Trauma ƒMajor cause of death from pelvic fracture (60 to 80 %) ƒ50 to 60 % of deaths due primarily to pelvic fracture occur within first nine hours of hospital admission ƒDegree of hemorrhage dependent on fracture type; truly massive in large posterior fractures ƒRetroperitoneum can accomodate large amount of blood and problem compounded with open fracture ƒ"Direct open" operative treatment seldom if ever indicated unless major vascular injury uncontrolled after angiography (however, surgical placement of external fixator often indicated & can be done in E.D.)

7. Pelvic Trauma : Initial Exam ƒLocal palpation : assess gross instability ƒCheck both hips ; associated hip Fx common ƒBlood at meatus (elicit by "milking" along the urethra first) : mandates urethrogram and cystogram ; Do not pass foley first ! ƒCareful neuro exam ƒVaginal & rectal exam ; if mucosa violated, patient must go to O.R. for diverting colostomy ƒEarly external fixator may be needed for unstable Fx ; another option is compressive external clamp

8. Pelvic Fractures : Radiology ƒAnteroposterior (AP) view shows most fx's ƒInlet view : shows inward fx displacement ƒOutlet view : provides true AP view of sacral foramina ƒTangential view : good for sacral fx & sacroiliac (SI) separation ƒJudet views (45 degrees oblique on both sides) –Help delineate acetabular fx's ƒComputed tomography (CT) : more accurate for posterior arch & acetabular fx's

9. Standard AP view of pelvis

10. Standard pelvic inlet view

11. Standard outlet view of pelvis

12. Indications for Pelvic Radiography in the Trauma Patient ƒAP view can be used as screening study –Other film choices on prior slide can then be ordered based on findings on the AP view ƒShould obtain in : –all major truncal trauma cases (especially if pain perception altered by head trauma, intoxication, etc.) with any abdominal pain or findings –patients with hip pain (may actually show pelvic Fx on the other side)

13. Additional Indications for Pelvic Films for the Trauma Patient ƒEcchymosis or tenderness over any pelvic bone ƒJoint pain with internal or external rotation of hips ƒAbnormal rectal exam ƒAbnormal lower extremity neuro exam ƒBlood at urethral meatus or hematuria

14. Pelvic Fractures : Diagnostic Peritoneal Lavage (DPL) ƒMay be required to quickly R/O intra- abdominal bleeding as cause for shock or hypotension ƒFalse positive rate higher than for isolated intraperitoneal injury ƒShould use supraumbilical open approach ƒWill miss diagnosis if hemorrhage is all retroperitioneal (so CT is better for Dx if patient stable enough to obtain scan)

15. M.A.S.T. (P.A.S.G.) ƒInflation may be helpful to control bleeding from pelvic fx (inflate abdominal compartment and leg compartments) if external fixator or large external clamp not available ƒIf unable to stabilize patient within 2 hours of application & suspected arterial bleeder present, then go to angiography ƒIf left on too long : risk of compartment syndrome in legs

16. Angiography for Pelvic Trauma ƒIndicated when hypovolemia persists and other sources of bleeding ruled out ƒConsider early for posterior arch fx's (associated with greater bleeding) ƒAllows Rx by vasopressin infusion or transcatheter embolization (wire coils or autologous clot) of bleeding vessel(s)

17. Classification of Pelvic Fractures STABLE Fracture of individual bones : no break in the pelvic ring Avulsion fractures anterior superior iliac spine anterior inferior iliac spine ischial tuberosity Fracture of the pubis or ischium (around the obturator foramen) Fracture of the wing of the ilium (Duverney's fracture) Fracture of the sacrum Fracture of the coccyx Single break in the pelvic ring Fracture of two ipsilateral rami Fracture near or subluxation of symphysis pubis Fracture near or subluxation of sacroiliac joint

18. Classification of Pelvic Fractures (cont.) UNSTABLE : DOUBLE BREAKS IN THE PELVIC RING Double vertical fracture or dislocation of the pubis (straddle fx) Double vertical fracture or dislocation of the pelvis(Malgaigne's fx) Severe multiple fractures (including sacral fracture) FRACTURES OF THE ACETABULUM Undisplaced Displaced

19. Types of pelvic fractures

20. Classification of Pelvic Fractures by Causative Mechanism ƒLateral compression –Most common cause ( > 50 %) –Associated with high incidence of brain injury ƒAnteroposterior compression –30 % of cases –High incidence of associated thorax and abdominal injuries ƒVertical shear –Less common –Usually from fall from height

21. Pelvic Avulsion Fractures ƒAnterior superior iliac spine avulsion (from pull from sartorius) ƒAnterior inferior iliac spine avulsion (from pull from rectus femoris) ƒIschial tuberosity avulsion (from pull from hamstrings) ƒRx : Analgesics, rest, may need temporary use of crutches ; ORIF rarely only for professional athletes

23. Ischial avulsion fracture due to hamstring or adductor muscle pull

24. 16 year old sprinter with pain in groin and buttocks from bilateral ischial apophyses avulsion fractures

25. Coccygeal Fractures ƒUsually caused by fall in sitting position ƒMay be caused by childbirth ƒNo need to reduce transrectally since reduction usually not maintained due to muscle pull ƒRx : Analgesics, stool softeners, sacral dough-nut ; consider coccygectomy if severe persistent pain (usually if > 1 month)

26. Sacral Fractures ƒIsolated sacral fx's usually transverse (vertical fx's always associated with Malgaigne fx) ƒDo not do bimanual reduction via rectum (may cause enlargement of presacral hematoma or conversion to contaminated open fx) ƒIf neurologic Sx, Rx by surgery ƒIf no neuro Sx : bed rest, analgesics, sacral corset

27. Type II Pelvic Fractures ƒSingle break in pelvic ring –Fracture of 2 ipsilateral rami –Subluxation of symphysis or SI joint ƒUsually mechanically stable ƒRx : analgesics, initial bed rest, then gradual ambulation advanced as tolerated

28. Lateral compression injury with overriding pubic symphysis

29. “Open-book” or anteroposterior compression injury

30. Type III Fractures ƒDouble breaks in pelvic ring ƒUnstable ƒAlmost all require surgery ƒAre one of criteria for referral to a trauma center

31. Straddle Fracture ƒFractures of both pubic rami on both sides or Fx of both rami on one side & a symphysis separation ƒ1/3 have lower GU tract injury ƒ1/3 have abdominal visceral injury

32. Straddle fracture with bladder rupture

33. Inlet view showing inward displacement of fracture fragments from a straddle fracture

34. Straddle fracture with “teardrop” bladder compressed by lateral hematomas

35. Malgaigne Fracture ƒAnterior and posterior pelvic ring fracture ƒAnterior : both pubic rami ƒPosterior : fx ilium, SI joint separation or sacral fx (vertical)

36. Malgaigne Fracture Associated Injuries ƒ50 % have intra-abdominal injury ƒ50 % have GU tract injury ƒ > 25 % have head injury ƒ > 25 % have chest injury

37. Malgaigne fracture with diastasis of pubic symphysis and left S-I joint and left posterior hip dislocation

38. Vertical shear injury with superior migration of right hemipelvis

39. Acetabular Fractures ƒPosterior lip fx –Most common –Associated with posterior hip dislocation ƒCentral or transverse fx ƒFracture of anterior (iliopubic) column ƒFracture of posterior (ilioischial) column (Walther fx)

41. Transverse acetabular fracture (note cystogram shows intact bladder)

42. Pelvic ring fracture and right acetabular fracture

43. Displaced posterior wall acetabular fracture

44. External pelvic fixator frame

45. Pelvic Fractures : Summary ƒAssess pelvis as part of secondary survey ƒTreat associated injuries ƒConsider sequence of fluid support : angiography : M.A.S.T. inflation : surgery (laparotomy or external fixator +/- plating) for continued bleeding from pelvic fractures ƒAssess for associated injuries to GU tract, rectum, and femurs